3: Respiratory System
Approved: 4 Nov 2010. Last amended: 8 Nov 2019.
On this page
-
Bronchodilators
-
Corticosteroids
-
Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors
-
Antihistamines, hyposensitisation, and allergic emergencies
-
Respiratory stimulants and pulmonary surfactants
-
Oxygen
-
Mucolytics
-
Aromatic inhalations
-
Cough preparations
-
Systemic nasal decongestants
-
Antifibrotics
-
Miscellaneous
3.1 Bronchodilators
3.1.1 Adrenoceptor agonists
3.1.1.1 Short-acting beta2 agonists (SABAs)
Salbutamol MDI
Easyhaler® Salbutamol
Salbutamol DPI
Salbutamol
nebules
3.1.1.2 Long-Acting Beta2 Agonists (LABAs)
Atimos Modulite® MDI
Formoterol
EasyHaler® Formoterol DPI
Formoterol
3.1.2 Antimuscarinic bronchodilators
3.1.2.1 Short-Acting Muscarinic Antagonists (SAMAs)
Ipratropium MDI
Ipratropium
nebules
3.1.2.2 Long-Acting Muscarinic Antagonists (LAMAs)
Incruse Ellipta® DPI
Umeclidinium
Sprivia Respimat® MDI
Tiotropium
3.1.3 Theophylline
Aminophylline (Phyllocontin®) m/r
Oral
Theophylline (Uniphyllin®) m/r
Oral
Aminophylline
Parenteral
3.1.4 Compound bronchodilator preparations
Anoro Ellipta® DPI
(umeclidinium 55mcg / vilanterol 22mcg)
Spiolto Respimat® MDI
(tiotropium 2.5mcg / olodaterol 2.5mcg)
3.1.5 Peak flow meters, inhaler devices and nebulisers
3.1.5.1 Peak flow meters
Peak Flow Meter (standard and low range)
3.1.5.2 Drug delivery devices - Spacers
Spacers should be replaced every 12 months but some may need changing at six months.
The spacer should be compatible with the MDI being used.
Spacers should be cleaned monthly. Follow manufacturer's instructions.
Space Chamber Plus
(one piece small volume spacer) – Compatible with most MDI devices
Volumatic
(two piece larger volume spacer) – Compatible with Clenil®, Flixotide®, Salamol®, Seretide®, Serevent®, Ventolin®
3.1.5.3 Sodium Chloride for Nebulisation
Recommended
Sodium chloride 0.9%
Specific Indication
Sodium chloride 7%
Cystic Fibrosis. Specialist use only
3.2 Corticosteroids
3.2.1 General
Prednisolone (oral)
Note: EC preparations are not recommended
Hydrocortisone (IV)
when oral unsuitable
3.2.2 Inhalers
Clenil Modulite® MDI
Beclometasone.
Prescribe by brand name: Qvar® is 2-2.5 times more potent than Clenil®, standard (CFC-containing) MDIs and dry powder inhalers at the same dose.
Easyhaler® Beclometasone DPI
Beclometasone
3.2.3 Compound Preparations
3.2.3.1 Asthma
First choice formulary recommended inhalers for adults (≥18 years):
Recommended
Combisal® MDI
Fluticasone & salmeterol
Fobumix Easyhaler® DPI
Budesonide & formoterol
Relvar Ellipta® DPI
Fluticasone furoate & vilanterol
Specific Indication
Fostair® MDI
Beclometasone & formoterol. Maintenance and Reliever Therapy (MART)
Note: The beclometasone in Fostair® is characterised by an extrafine particle size distribution (similar to QVAR®) which results in twice the potentcy of standard formulations such as Clenil.
3.2.3.2 COPD
Specific Indication
Fostair® 100/6 MDI
- Beclometasone & formoterol.
- ICS/LABA: Restricted use, as per COPD Guideline
Relvar Ellipta® 92/22 DPI
- Fluticasone furoate & vilanterol
- ICS/LABA: Restricted use, as per COPD Guideline
Trelegy Ellipta® DPI
- Fluticasone furoate, umeclidinium & vilanterol
- ICS/LAMA/LABA: Restricted to COPD patients who have demonstrated benefits with inhaled corticosteroids, and who would otherwise require 2 separate inhalers for ICS/LAMA/LABA therapy
Trimbow® MDI
- Beclometasone, formoterol & glycopyrronium
- ICS/LAMA/LABA: Restricted to COPD patients who have demonstrated benefits with inhaled corticosteroids, and who would otherwise require 2 separate inhalers for ICS/LAMA/LABA therapy
3.3 Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors
3.3.1 Cromoglicate and related therapy
None
3.3.2 Leukotriene receptor antagonists
Recommended
Montelukast
3.3.3 Phosphodiesterase type-4 inhibitors
Roflumilast
COPD, as per NICE TA461
3.4 Antihistamines, hyposensitisation, and allergic emergencies
3.4.1 Antihistamines
3.4.1.1 Non-sedating antihistamines
Recommended
Loratadine
Cetirizine
Fexofenadine
Specific Indication
Rupatadine
4th line for chronic idiopathic urticaria
3.4.1.2 Sedating antihistamines
Recommended
Chlorphenamine
Alternative
Hydroxyzine
Promethazine
3.4.1.3 Allergen immunotherapy
Specific Indication
Benralizumab
as per NICE TA565
Mepolizumab
as per NICE TA431
Omalizumab
as per NICE TA278, NICE TA339
Reslizumab
as per NICE TA479
Pharmalgen®
as per NICE TA246
Grazax®
Severe grass pollen allergy
Acarizax® (unlicensed)
Severe house dust mite allergy
3.4.2 Allergic emergencies
3.4.2.1 Anaphylaxis
Adrenaline
1 in 1,000: IM
Emerade®
Adrenaline 1 in 1,000: for self-administration IM
Adrenaline
1 in 10,000: slow IV injection reserved for severely ill patients where there is doubt about adequacy of the circulation and absorption from the IM site; with ECG monitoring.
Chlorphenamine
slow IV injection
Hydrocortisone (sodium succinate)
IV
3.4.2.2 Angioedema
C1-esterase inhibitor
Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria
Conestat alfa
Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria
Icatibant
Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria
Lanadelumab
Prevention of recurrent attacks of hereditary angioedema, as per NICE TA606
3.5 Respiratory stimulants and pulmonary surfactants
3.5.1 Respiratory stimulants
Doxapram
must be given under expert supervision and combined with active physiotherapy.
Mannitol (Osmohale®)
bronchial provocation test.
3.5.2 Pulmonary surfactants
None
3.6 Oxygen
See oxygen prescription chart and local guidelines
3.7 Mucolytics
Carbocisteine
Consider trial in COPD patients with chronic productive cough (as per NICE guidelines). Stop if no benefit within 4 weeks
Erdosteine
Acute exacerbation of COPD. Respiratory Consultants only. Max 10 days.
Mannitol (Bronchitol®)
dry powder for inhalation – Cystic Fibrosis as per NICE TA266
3.7.1 Dornase alfa
Dornase alfa
Cystic Fibrosis
3.7.2 Mucous Clearing Devices
Acapella Choice®
On the advice of a Respiratory Physiotherapist
3.8 Aromatic inhalations
None
3.9 Cough preparations
3.9.1 Cough suppressants
Recommended
Pholcodine
Methadone linctus
cough in terminal disease
Morphine
cough in terminal disease
3.9.2 Demulcent and expectorant cough preparations
Simple linctus
3.10 Systemic nasal decongestants
Systemic nasal decongestants are classified in the BNF as being of limited therapeutic value
3.11 Antifibrotics
Pirfenidone
Idiopathic Pulmonary Fibrosis: NICE TA504
Nintedanib
Idiopathic Pulmonary Fibrosis: NICE TA379
3.12 Miscellaneous
N-acetylcysteine
(oral) – Usual Interstitial Pneumonitis
On this page
-
Bronchodilators
-
Corticosteroids
-
Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors
-
Antihistamines, hyposensitisation, and allergic emergencies
-
Respiratory stimulants and pulmonary surfactants
-
Oxygen
-
Mucolytics
-
Aromatic inhalations
-
Cough preparations
-
Systemic nasal decongestants
-
Antifibrotics
-
Miscellaneous